D. Scott Jones, CHC, LHRM, is senior vice president of claims, risk management, and corporate compliance for American Healthcare
Providers Insurance Services, a national professional liability insurance management company with
headquarters in Philadelphia, PA. He has conducted quality and compliance
assessments in over 1,000 health care organizations across the United States over the last decade. He can be
reached at sjones@ahpis.com or by phone at 904/294-5633.
Can Electronic Medical Records
Really Improve Quality? The
Obama Administration Bets Yes
Step Right Up, Physicians — the Electronic Medical
Record Wizard Is Waiting For You
T
he Obama Administration placed strong backing for electronic medical record (EMR) development by making federal funds available to doctors that implement EMR systems. Under the American Recov-ery and Reinvestment Act (ARRA),1 funds are available for qualifi ed medical practices beginning in 2011.Interest in EMRs and electronic health records (EHRs) is also driven by market penetration. With estimates of over 2,000 vendors presently promoting products and ser-vices in the United States alone, a great deal of educa-tional information on electronic records is now available, even though much is slanted toward particular products.
The benefi ts of systems integration that results in a more closely integrated health care record are numerous; both direct and indirect. These include enhanced access to patient medical records, greater availability of studies and reports, potential mitigation of medical-legal and risk management matters through improved access to medi-cal information, and the ability to more closely commu-nicate results and follow up on recommendations. Inte-grated medical records have the potential to improve bill-ing performance and collection and enhance cash fl ow. Although many health care providers see the potential to improve quality of care as a positive aspect of these sys-tems, the potential to improve bottom-line performance may be a more immediate and potent factor.
EMR B
ECOMESP
OLITICALThe Obama Administration has placed a big bet on EMRs producing savings in terms of health quality and cost re-duction. A review of four major health care reform pro-posals2 indicates that quality improvement measures will be heavily dependent on efforts such as quality Howard B. Kessler, MD, is a practicing
radiologist with over 20 years experience in practice management and quality assurance and is a former medical director of radiology for Aetna. He is also president of Reimbursement Solutions of Mt. Laurel, New Jersey. He is an author and speaker on electronic
medical record technology for physician practices. He can be reached
at howardkessler@comcast.net. li y an 1 1 nd co 000 mplia lth e even h thhou b ug suranc Se fessionnal mentc liabili mpa , a y y wwith over vice 000 n th ve v e do n Uni es pr rs ted St sent ates y p a com anc s mpli ce m nsurranc d ce ers na m ers nal n c com P P nsur mpli Prov Prov nat nat ranc anc vide vide tion tion ce mana
measures and reporting initiatives, com-parative effectiveness research, health out-comes research and evaluation, health sys-tems effi ciency, patient safety research, in-teroperable standards, data collection and reporting, and provider accountability.3 All of these efforts are dependent on one com-mon element: the collection, dissemina-tion, and analysis of valid health care data. Most users and experts agree the current health care reimbursement system is inade-quate in terms of large-scale national data col-lection that could be meaningfully translated into broad-based system savings. ARRA de-livers an incentive the administration hopes will launch EMRs for thousands of physi-cians: billions in federal incentive funds for doctors who will adopt and install EMRs.
Signed into law on February 17, 2009, the 407-page ARRA commits $19.2 bil-lion to health care information technolo-gy (HIT) to promote the use of HIT for all health care providers. Incentive payments of $17.2 billion will be distributed to eligi-ble health care providers beginning in 2011, and through 2014.
To receive government cash incentives, health care entities must use a “certifi ed” EMR. Ominously, providers who have not adopted a certifi ed EMR by 2015 may be pe-nalized for the absence of a certifi ed elec-tronic medical record.
E
XCLUDEDORI
NCLUDED?
To obtain federal incentive payments, pro-viders must meet three requirements:
Eligibility
They must be an eligible professional who is a meaningful user of certifi ed EMR tech-nology. “Eligible professionals” include doctors of medicine, osteopathy, dental surgery, dental medicine, doctors of podi-atric medicine, optometry, chiropractors, and physician assistants.
Hospital-based professionals such as pa-thologists, emergency room physicians, and anesthesiologists are excluded. The law only requires that doctors be Medicare
pro-viders; it does not mandate that they see a certain percentage of Medicare patients.
Meaningful Use
To be a meaningful user, physicians must meet three requirements.
1. Utilize electronic prescribing functional-ity (e-Rx).
2. Use an EMR with electronic exchange of health information in a manner de-signed to improve the quality of health care. Specifi cally, the EMR must con-nect to other EMRs such as those at hospitals and other provider practices, a functionality commonly known as in-teroperability.
3. Provide for the submission of statistical information on quality of care to the government so it can determine if EMRs are improving the health care system. Possible benchmarks include attestation from a witness statement, submission of claims with appropriate coding, a survey response, or a report.
Use of Certifi ed EMRs
To be eligible for government-based funds under ARRA, medical personnel will be re-quired to use a certifi ed EMR. To be consid-ered certifi ed, the EMR must fulfi ll the fol-lowing criteria:
1. Include patient demographic and clini-cal health information, such as mediclini-cal history and problem lists.
2. Have the capacity to provide clinical de-cision support that includes physician order entry (to capture and query infor-mation relevant to health care quality). 3. In keeping with the second
“meaning-ful use” requirement, the system must exchange electronic health information with, and integrate such information from, other sources.
Certifi cation is provided by the Certifi -cation Commission for Healthcare Infor-mation Technology (CCHIT). The Certi-fi cation Commission is an independent, 501(c)3 nonprofi t organization recognized as certifi cation body for EHRs. The mission
overrnm nt ash inncentives, d p on will e prov be d ders c i b strib egi bute nnin d t ng to e in 2 gi-1, response, or a re ( l h ( lth hro ndth ar b h bi bl he f of eal f $ f $ le h lth 1 17 hea h ca 2 .2 althcac
of the CCHIT is to accelerate the adoption of robust, interoperable health information technology by creating a credible, effi cient certifi cation process.
The CCHIT certifi cation criteria represent a substantial body of work, developed by hun-dreds of volunteers through an open, multi-stakeholder, consensus-based process, and re-fi ned by testing and operational certire-fi cation over the past three years. With the passage of the ARRA and its requirements for certifi ca-tion, this process has attracted national inter-est from a much broader audience.
D
OLLARSFORD
ATAOnce these three criteria are met, ARRA al-lows for up to $44,000 in bonus payments to individual physicians who demonstrate meaningful EMR use by 2015. (See Figure 1) Note: EMR-earmarked federal funds will not be released up front to help purchase the systems but would be released beginning in 2011 when organizations have implement-ed electronic records and met the mean-ingful use criteria. Total funds released per practice are directly related to the number of health care professionals within the med-ical enterprise adopting EMRs.
B
UT…D
OESI
TI
MPROVEQ
UALITY?
Logically, it seems that consistent use of good EMR systems would improve quality. EMRs are even noted in physician continuing med-ical education programs as having the poten-tial to benefi t quality of care. In Defensible Documentation Using Electronic Medical Re-cords, CME author Donna B. Jones notes:
Many schools of thought equate an EMR with improved quality of care. Easily accessible health records and patient information may speed care and reduce the potential for medi-cal errors. Automated systems such as computerized drug reconcilia-tion programs or medicareconcilia-tion ad-verse event warnings can provide Physicians with immediate access to drug contraindications. Easily
missed data such as drug allergies can be readily accessed, or searched for in electronic fi les with appropri-ate database management. Patient identifi cation with a specifi c record or data can be verifi ed more easily using unique identifi ers, reducing the possibility of misdiagnosis. The Medicare Physician Quality Re-porting Initiative (PQRI) lists 100+ Quality Measures that may lead to improvements in quality of care. EMR is seen as a logical progression of a system that allows physicians to identify measures they wish to track, and provides payments for those that successfully monitor and report on measures. Physician Or-der Entry and the use of electron-ic prescriptions is one example of a Quality Measure used in Pay for Performance (P4P) systems.4
An EMR system cannot in itself prove quality of care. But it can im-prove the capture and fl ow of data to healthcare providers who make de-cisions regarding patient care, and it may decrease the time needed to identify, locate, and disseminate information that will contribute to correct medical decision making.5 Despite the vast numbers of arguments that EMRs will be a quality panacea, the pri-mary thesis — that simply using EMRs can improve quality — is yet unproven. In fact, poorly implemented and poorly used EMR systems may not improve quality but clut-ter up documented medical decision making with unnecessary and nonpertinent template materials not germane to the care of a par-ticular patient. In EMRs, as in all electronic documentation systems, GIGO (Garbage In, Garbage Out) is the one fi rm and fast rule.
Logically, the ready availability of com-plete patient health information, in an easy-to-use and readable format, should
pr d
ofessionals withhin thhhe mmed d-g c record eria. T s a otal nd fu m nd et s re he e m sed n-er An EMMR sy 0111 h ce racctic en se ro in 20 d ed 011 d d e ngf 1 w l ele ful whe ectr us crc
improve the physician or nonphysician provider’s ability to review and utilize that health information. By extension, better medical judgments should be possible, and certain types of medical malpractice claims may be avoided.
For example, a study reported in the Ar-chives of Internal Medicine on November 24, 2008, noted that a survey of 1,140 physicians of the Harvard Pilgrim Health System in Mas-sachusetts indicated a signifi cant difference in the number of malpractice claims brought against those that did not use an EMR system as opposed to those who did. According to the study, 6.1 percent of those respondents using EMRs reported malpractice claims; by com-parison, 10.8 percent of physicians who did not use an EMR reported claims.6
Importantly, the study also noted that the methodology used was logistic re-gression analysis of reported malpractice claims among respondents compared to paid claims data from the Massachusetts Board of Registry in Medicine (BRM) In-ternet site. Obviously, this excludes data on settled claims that may not have been
reportable. In its Conclu-sions, the report noted that results were “inconclu-sive” and that “Confi rma-tory studies are needed be-fore these results can have policy implications.”7
Statistical data support-ing the effi cacy of EMR or EHR use in reducing mal-practice claims are limited at present but are expect-ed to become more readily available as electronic records use matures and claims history is established. The often extend-ed time period between a mextend-edical injury event and closure of a legal case limits the availability of currently usable data.
Although EMR and EHR statistics are not individually available, a relevant re-view of the largest national database of closed medical malpractice claims can be conducted using the Data Sharing Reports generated by the Physician Insurers Asso-ciation of America (PIAA). PIAA consists of over 50 physician insurers that collec-tively provide coverage for approximately 60 percent of the private practice physi-cians in the United States. PIAA data in-cludes information on 239,756 closed claims from 1985 to 2008.
As an example, claims that involved a failure in the informed consent pro-cess (including “breach of contract”) were among the most prevalent claims reported in the 2009 PIAA Data Sharing Report. In all medical specialties, 14,985 closed claims reported an issue related
to these concerns, and 33.8 per-cent of those claims resulted in a payment to the plaintiff.8 To the extent that EMR can docu-ment and record patient educa-tion and informed consent pro-cesses, for example, it is logical that some of these claims may be mitigated.
Other signifi cant claims that may be impacted by electronic Figure 2: Other Claims That May Be Impacted
Malpractice Issue, All Medical Specialties # of claims % of claims paid Problems with patient history, exam, or
workup
5,702 48.93% Problems with medical records 5,220 61.42%
X-Ray error 4,591 41.23%
Communication between providers 4,484 39.78% Figure 1: Timetable
IF
ADOPTED
BY: 2011*
2012*
2013*
2014
2015
Year 1
$18,000
Year 2
$12,000 $18,000
Year 3
$8,000 $12,000
$15,000
Year 4
$4,000
$8,000
$12,000 $12,000
Year 5
$2,000
$4,000
$8,000
$8,000
Year 6
$0
$2,000
$4,000
$4,000
nt o l f tho e re po l ndent b s using r of mal hat did prac not ti us ce c e a claim n EM ms b M bro sys ht m g n cia ed rat ne ion o d by f Am th me h tt h os opppo ts ho um ag sa i in ach h n th gai hus h he n nst sett nu t thosesrecord use include the broad categories as reported by PIAA and shown in Figure 2.9
PIAA notes that across all medical spe-cialties, almost 30 percent of claims result in payment to plaintiffs.10 By extension, issues that appear to be fertile ground for improvements by EMRs and EHRs have a much higher percentage of payment and in some cases double that of all other types of claims.
But there are also more discrete stud-ies that show some aspects of electron-ic data gathering and collection may ac-tually improve quality of care. Fredrick Bloom, MD, the assistant chief quality officer of Geisinger Health System, was quoted recently as stating that “hardwir-ing” reminders into EMR systems could improve quality when followed by doc-tors. Bloom notes:
We focused on hardwiring remind-ers and alerts into the electron-ic health record to enhance care consistency and reliability — par-ticularly related to diabetes and coronary care as well as ensuring adults receive preventative health screenings.11
Meanwhile, CMS recently reported that in the Physician Quality Reporting Initia-tive (PQRI) more than 85,000 successful participants received more than $92 mil-lion in 2008. This compares to approxi-mately $36 million paid to 56,700 physician participants in 2007.12
T
HEF
INALA
NALYSIS…F
ORN
OWDo EMRs improve quality? Not without effective implementation and consistent utilization, but EMRs may promote qual-ity — through consistently available data that is readily locatable. From a profes-sional liability standpoint, there are many arguments that caution doctors against overuse of templates, reliance on com-puter-generated language, and failure to include all needed data. The same
argu-ments can be voiced by compliance pro-fessionals, who have seen their fair share of inadequate electronic documentation and aggressive systems that overbill for services rendered.
The jury is still out on EMRs as a qual-ity improvement tool — but the federal incentives to implement EMRs are very real, and hard to resist, and the potential threat of sanctions if providers do not implement EMR systems are also quite compelling.
All in all, it looks like physician use of EMRs is inevitable. Welcome to the Yellow Brick Road, physicians — the Wizard will see you now.
Endnotes:
1. The American Reinvestment and Recovery Act (ARRA), H.R.1, Jan. 6, 2009, frwebgate.access.gpo. gov/cgi-bin/getdoc.cgi?dbname=111_cong_ bills&docid=f:h1enr.pdf.
2. The Senate Finance Committee, America’s Healthy Future Act of 2009; The Senate HELP Committee, Affordable Health Choices Act (S.1679); The House Tri-Committee, America’s Affordable Health Choices Act of 2009 (H.R. 3200); President Obama’s Principles for Health Care Reform.
3. The Henry J. Kaiser Family Foundation, Focus on Health Reform: Health Care Reform Proposals, Oct. 15, 2009, www.kff.org/healthreform/upload/ healthreform_sbs_full.pdf.
4. Department of Health and Human Services (HHS), Centers for Medicare & Medicaid Services (CMS), Physician Quality Reporting Initiative, PQRI Overview, www.cms.hhs.gov/pqri.
5. Jones, Donna B., Defensible Documentation Using Electronic Medical Records (EMR); The Healthcare Providers Insurance Exchange (HPIX), September 19, 2008, www.hpix-ins.com.
6. Anunta Virapongse, MD, MPH; David W. Bates, MD, MSc; Ping Shi, MA; Chelsea A. Jenter, MPH; Lynn A. Volk, MHS; Ken Kleinman, ScD; Luke Sato, MD; Steven R. Simon, MD, MPH, Arch Intern Med. 2008;168(21):2362-2367, archinte.ama-assn. org/cgi/content/abstract/168/21/2362 (Accessed September 7, 2009).
7. Ibid, “Conclusions.”
8. Physician Insurers Association of America (PIAA),
Data Sharing Reports, Combined Specialties, Exhibit 9, p.vii, 2009 Edition. PIAA Research Department, 2275 Research Boulevard, Rockville, MD, 20850. datasharing@piaa.us, 7/9/2009. 9. Ibid, Claims by Associated Medical and Legal
Issues, Combined Specialties, Exhibit 9.
are as well s ens h urriing h record cy an d to d rel e ab nh bili anc ity e c — are
par AS.1679)ffordable HTheeaHo
ul t tic an is ea e i i c ers i ic con s a h he nsi tete
10. Ibid, Payment Analysis by Specialty Group, p. iv. 11. Healthcare Finance News, CMS Project Finds
Improved Practice Through P4P, Oct. 1, 2009, www. healthcarefinancenews.com.
Reprinted from Journal of Health Care Compliance, Volume 12, Number 1, January-February 2010, pages 41-46, with permission from CCH and Aspen Publishers, Wolters Kluwer businesses.
For permission to reprint, e-mail permissions@cch.com.
12. Medical Group Management Association (MGMA), Washington Connexion, Nov. 18, 2009,
CMS Releases Aggregate 2008 PQRI Results, www. mgmawashingtonconnexion.com.
